Insurance Form

For IKF & ISCF Sanctioned Events Please complete this form and the ADDITIONALLY REQUESTED FORMS from the FL Dean Website for your event Insurance. Once done, Fax this form below along with the following completed forms to 630.665.7294.
- For Fighter MEDICAL Insurance (Rates quoted on this form below): (Use Page 8 Of These Pages - Click HERE) With the page heading: "Accidental Medical Insurance Kickboxing/Mixed Martial Arts Wrestling Events" Fill out everything EXCEPT the "PLAN NUMBER" you want. This will be indicated by you on this page below.
- For Venue LIABILITY Insurance (IKF & ISCF Rate is $1 Million Coverage $450.00): (Page 6 Of These Pages - Click HERE) With the page heading: "Boxing/Martial Arts Event Liability Application Form"

Name of IKF/ISCF Promoter:__________________________________________ Where is event to be held: ______________________, ____________________ What is the DATE of your event: ____/____/____ Is the event ___IKF Sanctioned, ___ISCF Sanctioned or ____Both? Are you requesting Venue Liability for your event for $1 Million Coverage at the fee of $450.00? _____ Yes _____No Are you requesting Fighter Medical Insurance from one of the rate packages below? _____ Yes _____No If so, which "PLAN NUMBER BELOW" are you requesting: ________
PLAN NUMBER	Maximum Medical Benefit	Accidental Death Benefit	Deductible	Rates
1	$2,500.00	$2,500.00	$2,000.00	$460.00
2	$2,500.00	$2,500.00	$1,500.00	$590.00
3	$2,500.00	$2,500.00	$1,000.00	$700.00
4	$2,500.00	$2,500.00	$500.00	$770.00

5	$5,000.00	$5,000.00	$1,500.00	$790.00
6	$5,000.00	$5,000.00	$1,000.00	$840.00
7	$5,000.00	$5,000.00	$500.00	$910.00

8	$10,000.00	$10,000.00	$2,000.00	$880.00
9	$10,000.00	$10,000.00	$1,500.00	$1,100.00
10	$10,000.00	$10,000.00	$1,000.00	$1,190.00
11	$10,000.00	$10,000.00	$500.00	$1,400.00

12	$15,000.00	$15,000.00	$1,000.00	$1,490.00
13	$15,000.00	$15,000.00	$500.00	$1,800.00

14	$20,000.00	$20,000.00	$2,000.00	$1,300.00
15	$20,000.00	$20,000.00	$1,500.00	$1,900.00
16	$20,000.00	$20,000.00	$1,000.00	$2,400.00
17	$20,000.00	$20,000.00	$500.00	$2,750.00

18	$25,000.00	$25,000.00	$5,000.00	$800.00
19	$25,000.00	$25,000.00	$2,500.00	$1,880.00
20	$25,000.00	$25,000.00	$2,000.00	$2,050.00
21	$25,000.00	$25,000.00	$1,500.00	$2,280.00
22	$25,000.00	$25,000.00	$1,000.00	$2,570.00
23	$25,000.00	$25,000.00	$500.00	$2,900.00

24	$50,000.00	$50,000.00	$5,000.00	$920.00
25	$50,000.00	$50,000.00	$2,500.00	$2,900.00
26	$50,000.00	$50,000.00	$2,000.00	$3,460.00
27	$50,000.00	$50,000.00	$1,500.00	$3,750.00
28	$50,000.00	$50,000.00	$1,000.00	$4,000.00
29	$50,000.00	$50,000.00	$500.00	$4,250.00

30	$100,000.00	$100,000.00	$5,000.00	$3,870.00
31	$100,000.00	$100,000.00	$2,500.00	$4,620.00
32	$100,000.00	$100,000.00	$2,000.00	$5,120.00
33	$100,000.00	$100,000.00	$1,500.00	$5,590.00
34	$100,000.00	$100,000.00	$1,000.00	$5,900.00
35	$100,000.00	$100,000.00	$500.00	$7,700.00